‘Affected area: RUE, RLE, LUE, LLE PAE Waren ary ‘Assess Color, Sensation, Motion ‘Amputations: site RENAL/URINARY, sven Pain, difficulty, Incontinence, anuria General intervention: disposable brief Urine Character Device: Foley = Dialysis: w/ fistula (location, site assessment, bruit/thil,) NA fibuniNG sHiFr cis esi SE rgeeeua ys aera a Vital signs/time (TRENDING) 982 BP 2G/4% 02.96 P34 R20 3 oe Fall Risk/Braden Score ee ana Blood glucose monitoring results/insulin 19 a Intake and output NPO Diet: Food intake/Appetite/Nausea APS = ie chips oly Invasive Lines: 5 ea e IV solution and rate/hourly checks ___[Sedium Chloride 0.97% KCI LO meg Significant lab results lucose FF BUN LE Creatine TT 8 A Hl WE AR ‘Support system/SO involvement imife, Sof Patient education completed I Wok at this dime. NURSING DIAGNOSIS OUAte paid. SOAP NOTE (on above nursing diagnosis only) fee : Ob Ms ond wi a Jee acl bial A NGfabe. wor fhearter! Tho ube X01 (a 2 ee Chupcactive). carol este oa PE un eosled A aaiehtomns ia das 40 \ab tesutis gadicectan 2 uy On, re ef Sc eqnectt, = e oa rte END OF SHIFT CHECK-OUT Set repetied Sant ooo + Continue EMP, [Patient safe and comfortable [] Meds Administered {A Reported off to RN and Instructor J EMR Documentation Complete Student signatur © ea